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General NPI Number Information
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NPI Number | 1457652448
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Entity Type | Organization
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Legal Business Name | KDTK CORP LLC
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Dates
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Enumeration Date | 11/08/2010
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Last Update Date | 01/05/2018
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Provider Practice Location Address
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Address Line | 801 S RANCHO DR SUITE A4
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City | LAS VEGAS
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State | NV
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Zip | 89106-3854
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Country | US
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Telephone | 702-436-5279
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Fax | 702-776-8201
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Provider Business Mailing Address
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Address Line | PO BOX 35668
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City | LAS VEGAS
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State | NV
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Zip | 89133-5668
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Country | US
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Telephone | 702-436-5279
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Fax | 702-776-8201
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MS. KHANH BAO PHAM
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Credential | R.PH,CDE
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Telephone | 702-436-5279
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 332B00000X
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License Number State | NV
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